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Archived
June, 2007 |
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Highlights in Minority Health
& Health Disparities
August, 2006
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AUGUST IS NATIONAL IMMUNIZATION AWARENESS MONTH |
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Each year, National Immunization Awareness Month (NIAM) increases
awareness about immunization across the lifespan as parents and
children prepare for the return to school, and the medical community
begins preparations for the upcoming flu season.
Immunization has been cited as one of the top ten public
health achievements of the 20th century.
Yet the burden of vaccine-preventable diseases in adults in the U.S.
is staggering – more than 40,000 adults die each year
from vaccine-preventable diseases.1 |
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Each year approximately 200,000 people in the United States are
hospitalized because of influenza; an average of 36,000 people die
annually due to influenza and its complications– most are people 65
years of age and over. Annually there are approximately 40,000 cases
of invasive pneumococcal disease in the United States and one-third
of these cases occur in people 65 and older.
About half of the 5,000 annual deaths from invasive
pneumococcal disease occur in the elderly.1 |
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Influenza vaccine coverage rates were up from 31% in
1989 to 65% in 2004, and pneumococcal vaccine coverage rates
were up from 14% to 57%. Despite these increases,
adult vaccination
coverage rates for certain racial and ethnic groups remain
substantially below the general population. On
the national level, vaccination coverage among U.S. preschool
children is at or near record high levels. This successful
achievement of the past decade has largely reduced the marked racial
and ethnic disparities in vaccination coverage rates among children
that existed during the late 1980s and early 1990s. While
data shows disparities have been greatly reduced when examining
childhood coverage rates for individual vaccines, there is rising
concern about data indicating that in recent years racial and ethnic
disparities for series complete childhood vaccination coverage has
been increasing. |
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EXAMPLES
OF IMPORTANT DISPARITIES |
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Blacks or African Americans |
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African Americans have significantly lower influenza and pneumococal
immunization rates compared to the rest of the population. For
adults aged 65 years and over, the percent of persons receiving a
flu shot during the past 12 months was 68.7% for non-Hispanic white
persons and 48% for non-Hispanic black persons. |
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The
gap for pneumococcal vaccination coverage is even wider.
Historically, blacks in the United States have had a higher
incidence of invasive pneumococcal disease than whites, with the
widest disparities occurring among children in the first years of
life and among adults 18 to 64 years old. Among children,
before vaccine introduced in 2000, incidence among blacks was 2.9
times higher than among whites; by 2002, the black-white rate ratio
was reduced to 2.2. The percent of adults aged 65 years and
over who had ever received a pneumococcal vaccination was 59.6% for non-Hispanic white persons,
and 36.9% for non-Hispanic black persons. |
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Although disparities in childhood immunization coverage have been
greatly reduced for most vaccines that children age 19-35
months routinely receive, disparities for full series immunization
coverage (4:3:1:3:3 series completion)* have not been eliminated.
From 1996-2001, among the immunization coverage gap between
non-Hispanic white children and non-Hispanic black children widened
by an average of 1.1% each year. The growing disparity is due
to failure of series completion rates among African Americans to
increase substantially during the period 1996 to 2002 (66.8% to
67.7%), while series completion rates among whites increased (68.9%
to 77.7%) during this same period.2
In a follow-up study,
vaccination coverage from 1998-2003, the differences between the
full series vaccination coverage of white and African American
children within income groups for each U.S. census region were
examined. The study found that disparities exist in at least
three of the four regions specifically the Northeast, South and
Midwest regions. Widening national level disparity in full
series immunization coverage appears to be primarily attributable to
trends observed among African American households at or above the
federal poverty level in the Northeast census region. Although
the disparity trend in the Midwest was narrowing disparities in that
regions persist. There was little change in disparities in the
South.3 |
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Hispanics or Latinos |
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In 2003, Hispanic/Latino persons were less likely than non-Hispanic
white persons to have received a flu shot during the past 12 months
or to have ever received a pneumococcal vaccination. For adults
aged 65 years and over, the percent of persons receiving a flu shot
during the past 12 months was 45.4% for Hispanic/Latino persons and
68.7% for non-Hispanic white persons. The percent of adults aged 65
years and over who had ever received a pneumococcal vaccination was
31.0% for Hispanic/Latino persons and 59.6% for non-Hispanic white
persons. |
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Disparities in childhood immunization coverage for Hispanics, just
as for African Americans, have been greatly reduced for most
vaccines that children routinely receive. Disparities in the full
immunization series (4:3:1:3:3 completion)* have not been
eliminated. From 1996-2001 the difference in series vaccination
coverage rates between non-Hispanic whites and Hispanics widened by
an average 0.5%. During this period vaccination coverage rates for
white children 19-35 months of age increased from 68.9% to 77.7%
while Hispanic vaccination coverage rates only increased from 63.7%
to 72.2%. |
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Hepatitis A is a vaccine-preventable disease that is transmitted
when fecal material is ingested. Uncooked foods or water supply
contamination are the primary reasons for more widespread
occurrences. Person-to person transmission is more common and occurs
frequently among close contacts, or in extended family settings.
During the pre-vaccine era, the reported incidence of hepatitis A
was highest among children aged 5-14 years with rates among
Hispanics approximately three times higher than rates among
non-Hispanics. A childhood immunization strategy has been
implemented incrementally. Initially vaccination recommendations
focused on particular high risk groups and specific U.S. areas, the
west and southwest where there were high disease rates. Although
vaccination implementation strategies greatly improved disease
prevention, in 2004, states without widespread hepatitis A
vaccination of children had a disease rate was seven times higher
among Hispanic children and four times higher among the entire
Hispanic population. In 2006 recommendations for this vaccine were
expanded to include all children aged 12-23 months. The
recommendation was expanded because the highest rates of disease
were occurring among children in parts of the country where
vaccination had not been recommended. This recent update is
considered a final step in an incremental strategy to address
routine hepatitis A vaccination of children nationwide.4 |
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Asian Americans or Pacific Islanders |
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Although relatively rare in the United States, hepatitis B is
endemic in parts of Asia where hundreds of millions of individuals
may be infected. HBV is transmitted horizontally by blood and blood
products and sexual transmission. It is also transmitted vertically
from mother to infant in the Perinatal period which is a major mode
of transmission in regions where hepatitis B is endemic. |
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Immunization with hepatitis B vaccine is the most effective means of
preventing hepatitis B virus infection and its consequences.
However, while the rate of acute Hepatitis B (HBV) among Asian
Americans and Pacific Islanders (AAPIs) has been decreasing, the
reported rate in 2001 was more than twice as high among AAPIs (2.95
per 100,000 population) as among white Americans (1.31 per 100,000
population). |
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American Indians or Alaska Natives |
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In FY2005, the vaccination coverage rate for
AI/ANs age 65 or older was 59% for influenza vaccination and 69% for
pneumococcal vaccination in Indian Health Service (IHS) healthcare
facilities.5 This compares to 65.5% of
all Americans aged 65 or older who received an influenza vaccination in
2003, and 55.6% of all Americans aged 65 or older who had ever received a
pneumococcal vaccination.6 |
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ADDRESSING DISPARITIES - WHAT WORKS - EVIDENCE-BASED STRATEGIES |
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The
Guide to Community Preventive Services (Community Guide) serves as a
premier source of high quality information on those public health
interventions and policies proven to work in promoting health and
preventing disease, injury, and impairment. The Community Guide
review of vaccine-preventable disease studies
consistently show that focusing efforts to improve coverage on
health care providers, as well as health care systems, is the most
effective means of raising vaccine coverage in adults. For example,
all health care providers should assess routinely the vaccination
status of their patients. Likewise, health plans should develop
mechanisms for assessing the vaccination status of their
participants. Also, nursing home facilities and hospitals should
ensure that policies exist to promote vaccination.4 |
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For children living
in poverty, childhood vaccination efforts need to be strengthened.
Substantial numbers of under-vaccinated children remain in some
areas, particularly the large urban areas with traditionally
underserved populations, creating great concern because of the
potential for outbreaks of disease. Reasons for racial disparities
in coverage rates for the full vaccination series among pre-school
aged children are incompletely understood. Further studies are
planned to develop an understanding of the underlying causes of
these disparities so that effective strategies to reduce the
disparities can be developed. |
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FEDERAL PROGRAMS THAT ADDRESS RACIAL/ETHNIC
DISPARITIES IN IMMUNIZATION |
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CDC’s National Immunization Program (NIP) strives to prevent disease,
disability, and death in children and adults through vaccination.
NIP is committed to promoting immunization at every stage of life,
providing leadership on vaccines and immunization, strengthening and
communicating immunization science, establishing partnerships and
fostering collaboration, providing immunization education and
information, and improving health in the United States and globally.
NIP supports the following programs: |
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Racial and Ethnic Adult Disparities Immunization Initiative (READII) |
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The Department of Health and Human Services (HHS) has made the
elimination of racial and ethnic disparities in influenza and
pneumococcal vaccination coverage for people 65 years of age and
older a priority. To address these disparities and to assist in
reaching the 2010 national health goal of 90% influenza and
pneumococcal vaccination rates among persons 65 and over, HHS,
in collaboration with the Centers for Disease Control and
Prevention (CDC) and other federal partners, launched the Racial
and Ethnic Adult Disparities in Immunization Initiative (READII)
in July 2002. READII was a two-year demonstration project
conducted in five sites (Chicago,
IL;
Rochester, NY;
San Antonio, TX;
Milwaukee, WI; and 19 counties in the
Mississippi Delta region) to improve influenza and
pneumococcal vaccination rates for African-Americans and
Hispanics 65 years of age and older. CDC implemented the READII
project with the support of the Centers for Medicare & Medicaid
Services, the Health Resources and Services Administration, the
Administration on Aging, the Agency for Healthcare Research and
Quality, and other federal agencies. |
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Vaccines for Children (VFC) |
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Since 1994, the Vaccines for Children (VFC) program has allowed
eligible children to receive vaccinations as part of routine
care, supporting the reintegration of vaccination and primary
care. Based on the total doses of routinely recommended
pediatric vaccines distributed in the U.S., the VFC program
served about 40% of the childhood population in 2004. The VFC
program provides publicly purchased vaccines for use by all
participating providers. These vaccines are given to eligible
children without cost to the provider or the parent. The VFC
program provides immunizations for children who are uninsured,
Medicaid recipients, Native Americans, or Alaska Natives at
their doctors' offices. VFC also provides immunizations for
children whose insurance does not cover immunizations at
participating federally qualified health centers (FQHCs) and
rural health clinics (RHCs). The program has contributed to
high immunization rates and reduced delays in immunizations and,
subsequently, the risk of serious illness or death from
vaccine-preventable diseases. |
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National Asian Women's Health Organization (NAWHO) |
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The National Asian Woman’s Health Organization (NAWHO) is one of
the largest organizations in the country working toward improved
health of Asian Americans. This cooperative agreement helps
support Promoting Prevention for Healthy Communities: The
National Asian American Immunization Project. Activities by
grantees and sub-grantees will target cultural subgroups in
Asian-American communities in Atlanta, GA, Denver, CO, Long
Beach, CA, Los Angeles, CA, San Francisco, CA, Palo Alto, CA,
New York, NY, Stoneham, MA, Portland, OR and Chicago, IL.
Activities include partnership-building, community
capacity-building, and educating healthcare providers and the
public. |
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Specifically, NAWHO will:
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provide cultural competence workshops to
providers of Asian Americans, |
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create and distribute linguistically appropriate
and culturally sensitive educational materials, and
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work with mass media sources to develop and
promote immunization campaign messages. |
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Black Women's Health Imperative |
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Established in 1983, the Black Women’s Health Imperative works
to move health issues for Black women to the top of the agenda
for legislative, policy, and the research agenda of the nation.
With a membership of more than 150,000 and because Black women
are the primary decision makers regarding health matters for the
entire family, they are uniquely positioned to implement
positive change in immunization programs targeting African
American families.
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Specifically, the Imperative will:
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collaborate with faith based organizations such
as the African American Episcopal Church, community
based organizations such as Mocha Moms Inc., the
National Black Nurses Association, and local and
state health departments to improve immunization
coverage among African Americans, |
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They will develop resources that will address
the knowledge, attitudes, and beliefs of African
American families toward immunization, and |
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increase capacity of providers to implement
culturally sensitive strategies into their practice. |
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Migrant Clinicians Network (MCN) |
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The Migrant Clinicians Network was founded in 1984 and is the
oldest and second largest clinical network devoted to the care
of the underserved. Together in partnership with Texas Tech
University Health Science Center, they will be focusing on
projects that address immunization issues specific to minority
populations (primarily Hispanic) and migrant populations.
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Specifically, MCN will:
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Provide training and technical assistance to
migrant health centers, head start schools and state
and local health departments to improve immunization
coverage, |
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Develop educational materials and programs
utilizing the animation series called Pepin to
address immunization issues such as vaccine safety,
administration, and the recommended schedule, and |
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Educate providers on cultural sensitivity and
the elimination of barriers to providing medical
care to mobile underserved populations. |
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Indian Health Service (IHS) |
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IHS clinics are encouraged to provide influenza and pneumococcal
vaccine during clinic visits and during mass immunization
clinics in accordance with ACIP guidelines. Educating patients
is a part of the strategy to ensure influenza vaccine is
provided. The proposed FY 2005 IHS budget will support the
capacity for sites to continue existing strategies and maintain
current immunization coverage levels in the face of population
growth. |
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FOR MORE INFORMATION |
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CDC’s Office of Minority health (OMH) |
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Eliminate Disparities in Adult and Child Immunization Rates |
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National Immunization Program (NIP) |
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Parents Guide to Childhood Immunization |
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Protect the Circle of Life: Immunize Our Nations |
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Racial and Ethnic Adult Disparities Immunization Initiative (READII) |
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Vaccines for Children (VFC) |
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National Center for Infectious Diseases
(NCID) |
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HBV: A Silent Killer |
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Preventing Emerging Infectious Diseases: A Strategy for the 21st
Century |
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Department of Health and Human Services (HHS) |
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National Vaccine Program Office |
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Indian Health Service |
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Healthy People 2010 |
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Chapter 14: Immunization and Infectious Diseases |
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The Community Guide |
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Vaccine Preventable Diseases Improving Coverage in
Children, Adolescents and Adults |
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*Series completion is defined as up to date for the 4:3:1:3:3
series (4 or more doses of diphtheria and tetanus toxoids and [acellular]
pertussis vaccine; 3 or more doses of poliovirus vaccine; 1 or more
doses of measles-containing vaccine; 3 or more doses of
Haemophilus influenzae type b vaccine; and 3 or more doses of
hepatitis B vaccine. |
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SOURCES |
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1. |
Racial and Ethnic Adult Disparities in Immunization Initiative
(READII) |
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2. |
Chu et. al.
Racial/Ethnic Disparities in Preschool Immunizations: United
States, 1996-2001. American Journal of Public Health June 2004,
Vol 94, No. 6 |
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3. |
Barker et. al.
Disparities between white and African-American children in
immunization coverage. Journal National Medical Association.
2006 Feb;98(2):130-5. |
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4. |
The Community Guide to Preventive Services
Vaccine Preventable Diseases: Improving Coverage in Children,
Adolescents,and Adults |
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5. |
“Indian Health Service Twelve-Area Summary Report, GPRA 2005”,
IHS Division of Epidemiology and Disease Prevention. |
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6. |
NCHS, Health US, 2005, table 76 |
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